More than Sad: Suicide Prevention Education for Teachers and Other School Personnel

More than Sad:
Suicide Prevention Education for Teachers
       and Other School Personnel

                    Cindy Wiley
              cwiley@shelbyed.k12.al.us
       American Foundation for Suicide Prevention
              120 Wall Street, 22nd Floor
                 New York, NY 10005
                    212.363.3500
                    www.afsp.org

Introduction
to the Program
Program goals

1.       Increase understanding of:
           Problem of youth suicide
           Suicide risk factors
           Treatment and prevention of suicidal behavior in adolescents

2.       Increase knowledge of warning signs of youth suicide so
         those who work with teens are better prepared to identify
         and refer at-risk students

                                                                           2

Understanding the
Problem of Suicide
   In 2008, 36,035 people in the U.S. died by suicide

   U.S. suicide rate = 11.5 (11.5 suicides for every 100,000
    people)

   During 2008-2009 – 8.3 million adults (3.7% of total) reported
    having suicidal thoughts

   During the same time period, 2.2 million adults (1% of total)
    reported making a suicide plan.

   4,324 people under age 25 died by suicide (12.5% of total)
                                                                    3

Trends by gender & ethnicity
Ages 10 and older

                               4

Youth Suicide Rates
by Race/Ethnicity (Ages 15-24)
Racial/Ethnic Group                    Rate*

American Indians and Alaskan Natives    20.3
Whites                                  10.4
Asian and Pacific Islander               8.8
Hispanics                                7.2
Blacks                                   6.0

*Number of suicides per 100,000
 population, 2007
                                           5

Trends by gender & ethnicity
Ages 15-24

                               6

High School Facts

                    7

Suicide Attempts
   No official count; emergency room statistics underestimate
    extent of problem

   In U.S. overall, 25 suicide attempts estimated to occur for each
    suicide death

   Among youth aged 10-24, 65-200 attempts for each suicide

   Among the elderly, 4 attempts for each suicide

   Adolescent girls report twice as many suicide attempts as boys

                                                                  8

Suicidal Ideation
   Suicide is the 3rd leading cause of death for adolescents and
    young adults (ages 15–24)

   “Ideation” – thinking about or planning for suicide

   About 16% of students in grades 9-12 – 1 of every 7 – report
    seriously considering suicide in the past year

   About 13% – 1 of every 9 – report making a suicide plan

   About 8% of students in grades 9-12 – 1 of every 14 – report
    making a suicide attempt in the past year

   Suicide rate for youth (ages 15-24) = 9.8                       9

How Can
Teachers Help?
Key tasks

   Identification of at-risk students
   Referral for assessment and evaluation, according to school’s
    protocol or policy

Teachers and other school personnel must know how to
  recognize “risk” in youth

                                                                    10

Film, More Than Sad:
Preventing Teen Suicide

   Provides an overview of mental disorders in teens that may
    end in suicide

   Identifies behaviors that suggest a student may be at risk

   Discusses steps that teacher and other personnel can take to
    ensure that these students get help

   Introduces concepts that will be discussed in later sections of
    this program

                                                                      11

Risk Factors
for Teen Suicide
   Key suicide risk factor for all age groups is an undiagnosed,
    untreated or ineffectively treated mental disorder

   90% of people who die by suicide have a mental disorder

   In teens, suicide risk is most clearly linked to 7 mental
    disorders, often with overlapping symptoms:

     Major Depressive Disorder             Conduct Disorder
     Bipolar Disorder                      Eating Disorders
     Generalized Anxiety Disorder          Schizophrenia
     Substance Use Disorders

                                                                    12

Major Depressive
Disorder (MDD)
 Key symptoms in teens are sad, depressed, angry or irritable
  mood and lack of interest or pleasure in activities the teen used
  to enjoy, lasting at least 2 weeks

 Other symptoms
    Changes in appetite                 Worthlessness/guilt
    Sleep disturbances                  Inability to concentrate
    Slowed or agitated movement         Recurrent thoughts of death
    Fatigue/loss of energy              or suicide, self-harm behavior
 Symptoms represent a clear change from normal and are
  generally observed in several different contexts

                                                                   13

Facts
about MDD
 8-12% of teens suffer from major depression
 MDD is more common in females than males
 MDD is caused by changes in brain chemistry that may result
  from stressful life events, but also from genetic or other
  internal factors
 MDD may occur in teens who are appear to “have it all”
 MDD in teens is often expressed through physical complaints
  (stomach distress, headaches)
 MDD is the mental disorder most frequently associated with
  suicide in both teens and adults

                                                                14

Bipolar Disorder
   “Manic-depression” – alternating episodes of depression and
    mania
   Manic symptoms
    Inflated self-esteem/grandiosity     Distractibility
    Decreased need for sleep             Agitated speech/movement
    Talking much more than usual         Involvement in risky activities
    Flight of ideas
   Manic symptoms last at least 1 week and cause clear social,
    academic or work impairment
   In many cases, manic symptoms are less severe or “hypomanic”

                                                                    15

Facts about
Bipolar Disorder
   Bipolar disorder usually begins with depressive episode; can
    lead to misdiagnosis

   Bipolar disorder is less common than depression in both teens
    and adults

   Unlike depression, occurs as frequently in boys as in girls

   Conveys especially high risk for suicide

   Suicide risk highest
    - during depressive rather than manic episodes
    - when rapid “cycling” of manic and depressive symptoms occurs
    - in “mixed” episodes (depressive and manic symptoms present at
       same time)                                                     16

Generalized
Anxiety Disorder (GAD)
   Key characteristic of GAD is excessive, uncontrolled worry,
    occurring more days than not for a period of 6 months (e.g.,
    persistent worry about tests, speaking in class)
   Symptoms
    Restlessness/keyed up                Irritability
    Being easily fatigued                Muscle tension
    Difficulty concentrating             Sleep disturbances
   GAD is one of many different anxiety disorders that may
    affect teens – e.g., social anxiety disorder, obsessive-
    compulsive disorder, panic disorder. All anxiety disorders
    share an anxious, fearful mood, leading to other symptoms
    and disability
                                                                   17

Facts
about GAD
   Girls are more likely than boys to have GAD

   Teens who are “perfectionists” may be especially vulnerable

   Severe anxiety is often part of depression in teens

   Like depression, anxiety is often expressed through physical
    symptoms (racing heart, shortness of breath)

   Overwhelming anxiety can lead teens to feel they can’t go on
    and to thinking about or planning for suicide

                                                                   18

Substance
Use Disorders
   Two main types: substance dependence and substance abuse
   Each involves maladaptive pattern of drug or alcohol use over
    12 months, leading to significant impairment or distress
   Symptoms of substance dependence
    Increasing tolerance of the substance
    Withdrawal effects when not used
    Taking larger amounts, over a longer period, than intended
    Persistent desire or unsuccessful efforts to cut down use
    Spending considerable time obtaining, using or recovering from the
    substance
    Giving up activities because of the substance use
    Continued use despite knowing it is causing problems
                                                                         19

Substance
Use Disorders…
   Symptoms of substance abuse
    Failing to fulfill major role obligations because of substance use
    Recurrent substance use in physically hazardous situations
    Recurrent substance-related legal problems
    Continued use despite persistent social or interpersonal problems
    caused by effects of substance use

   Substance dependence and abuse may exist as a single
    disorder or in addition to another mental disorder, such as
    major depression or an anxiety disorder

                                                                         20

Facts about
Substance Use Disorders
   Alcohol use disorders are especially common among teens,
    often beginning with the desire to be part of a peer group
   Although commonly used to cope with stress, depression or
    anxiety, alcohol almost always worsens these problems
   Other effects of alcohol and other drugs on teens
    Increased irritability and anger
    Relationship problems (peers and family)
    Sleep disturbances
    Reduced concentration and ability to cope with stress
    Family conflict over substance use
    Legal problems
    Increased suicide risk due to decreased inhibition and increased
    impulsivity
                                                                       21

Conduct Disorder
   Repetitive, persistent pattern in children or adolescents of
    violating rights of others, rules or social norms; occurs over
    12 months and results in significant impairment in functioning
   Symptoms
    Bullying/threatening others          Fire-setting
    Physical fights                      Destroying property
    Using a weapon                       Breaking into houses/cars
    Physical cruelty to people           Lying/conning others
    Physical cruelty to animals          Staying out all night
    Mugging, shoplifting, stealing       Running away from home
    Forced sexual activity               Frequent school truancy

                                                                     22

Facts about
Conduct Disorder
   Dislike of conduct-disordered youth because of their anti-
    social behavior may impede recognition of this serious mental
    disorder

   There is a strong genetic component to the aggressiveness
    seen in conduct disorder

   Much more frequent in boys than in girls

   Frequently overlaps with AD/HD, depression and substance
    use disorder

   Associated with high rates of suicidal ideation, suicide
    attempts and completed suicide
                                                                23

Eating Disorders
   Two main types: anorexia nervosa and bulimia nervosa
   Symptoms of anorexia nervosa
    Refusal to maintain body weight at minimally normal level for age
    and height
    Intense fear of gaining weight
    Disturbance in how body weight or shape is experienced, or denial
    of low body weight
    In females, delay of menarche or cessation of menstrual cycles

                                                                        24

Eating Disorders…
   Symptoms of bulimia nervosa
    Recurrent episodes of uncontrollable binge eating (at least 2x per
    week for 3 months)
    Recurrent inappropriate behaviors to compensate for binge eating
    and avoid gaining weight (e.g., vomiting, misuse of laxatives,
    excessive exercise)
    Self-evaluation unduly influenced by body shape and weight

   Eating disorders are strongly linked to other mental disorders,
    especially depression and anxiety

                                                                         25

Facts about
Eating Disorders
   Far more common among females than among males
   Typically begin between ages 13 and 20
   10-20% of people with anorexia nervosa die prematurely,
    often by suicide
   Women aged 15-24 with an eating disorder have a suicide
    rate 60 times the expected rate for young women overall
   People with eating disorders tend to use particularly violent
    suicide methods
   Other characteristics that contribute to lethality of suicide
    attempts
    Perfectionistic, obsessive, secretive, socially isolated
    Low weight, electrolyte abnormalities

                                                                    26

Schizophrenia
   Schizophrenia is a psychotic disorder that causes people to
    have difficulty interpreting reality
   Two sets of symptoms- positive and negative; both are
    abnormal
   Positive symptoms
    Delusions (fixed false beliefs, e.g., that others are controlling one’s
    thoughts, or are trying to cause one harm)
    Hallucinations (fixed false sensory perceptions, e.g. hearing voices,
    seeing or smelling things that are not there in reality)
    Disorganized or incoherent speech
    Excessive, purposeless movements, or catatonic, immobile behavior

                                                                              27

Schizophrenia…

   Negative symptoms
    Low energy or motivation
    Lack of emotion
    Difficulty expressing thoughts or elaborating responses
    Difficulty integrating thoughts, feelings and behavior
    Blank facial expression
    Social withdrawal, isolation
    Inappropriate social skills

                                                              28

Facts about
Schizophrenia
   Affects both males and females
   Typically begins to develop in very late adolescence or early
    adulthood
   Earlier onset in males (ages 15-25) than in females (ages 25-
    35)
   Strongly linked to genetic factors
   People with schizophrenia have very high rates of suicidal
    behavior
    40% make one or more suicide attempts
    10% die by suicide

                                                                    29

Other Individual
Suicide Risk Factors
Impulsivity
   Contributes to suicidal behavior, especially in context of depression
    or bipolar disorder
   Associated with dysregulated brain chemistry; may explain why some
    teens with these disorders engage in suicidal behaviors while others
    do not
Family History
   Many mental disorders run in families, due to genetic factors
   Suicide attempts and completed suicide are more frequent in teens
    with a relative who has attempted or died by suicide
Prior Suicide Attempt
   30-40% of teens who die by suicide have made a prior attempt
                                                                            30

Situational Factors
that Increase Suicide Risk
   Although mental disorders are the most significant cause of
    suicide in teens and adults, stressful life events and other
    situational factors may trigger suicidal behavior

   Among teens, such factors may include
    Physical and sexual abuse
    Death or other trauma in the family
    Persistent serious family conflict
    Traumatic break-ups of romantic relationships
    Trouble with the law
    School failures and other major disappointments
    Bullying, harassment or victimization by peers

                                                                   31

Situational Factors…
   The majority of teens who have these experiences do NOT
    become suicidal

   In some teens, these stressful experiences can precipitate
    depression, anxiety or another mental disorder, which in turn
    increases suicide risk

   Mental disorders themselves can precipitate stressful life
    events, such as conflict with family and peers, relationship
    break-ups or school failures, which then exacerbate the
    underlying illness

                                                                    32

Situational Factors
Most Relevant to Schools

History of Physical and Sexual Abuse
   Controlling for other risk factors, including individual and parental
    mental disorders, risk of suicide attempt is 5x greater in adolescents
    with a history of physical abuse
   Risk of suicide attempt is more than 7x greater among adolescents
    with a history of sexual abuse

                                                                         33

Situational Factors…
Bullying
   Common problem in schools in the U.S. and abroad
   Higher rates of depression, suicidal ideation and suicidal behavior
    found in both victims and perpetrators of bullying
   Female victims and perpetrators may be especially vulnerable
   Pre-existing depression may explain suicidal behavior in some teens
    involved in bullying
   Bullying likely leads to depression in other teens, increasing suicidal
    behavior

                                                                              34

Situational Factors…
Sexual Orientation and Gender Identity
   GLBT youth have elevated rates of depression compared to
    heterosexual/straight youth, and report more frequent suicidal
    ideation and behavior
   Contributing factors include family rejection, high rates of alcohol or
    drug use and social ostracism and bullying by peers
Trouble with the Law
   Teens with a history of problems with the law have increased risk of
    suicide attempts and completed suicide
   Suicide in juvenile detention and correctional facilities is 4 times
    greater than in overall youth population

                                                                              35

Situational Factors…
Exposure to Suicide
   Suicide risk is increased in teens exposed to another’s suicide
   Can result in suicide “clusters”
   Factors increasing “suicide contagion” include romanticized or
    glamorized reports of the suicide and idealization of the suicide
    victim
   Social networking websites may increase exposure among teens
Access to Firearms
   Access to firearms increases suicide risk, especially among teens with
    a mental disorder

                                                                        36

Suicide
Warning Signs
 Suicide risk factors endure over some period of time, while
  warning signs signal imminent suicide risk

 Clearest warning signs for suicide are behaviors that indicate
  the person is thinking about or planning for suicide, or is
  preoccupied or obsessed with death
   Looking for ways to kill oneself (e.g., searching the internet for
   methods, seeking access to firearms or other means for suicide)
   Talking or writing about suicide
   Talking or writing about death in a way that suggests preoccupation

                                                                        37

Barriers to
Treatment of At-Risk Teens
   Many at-risk teens do not get needed treatment, including an
    estimated 2/3 of those with depression
   Reasons
    Neither teens nor the adults who are close to them recognize
    symptoms as a treatable illness
    Fear of what treatment might involve
    Belief that nothing can help
    Perception that seeking help is a sign of weakness or failure
    Feeling too embarrassed to seek help
    Belief that adults aren’t receptive to teens’ mental health problems
   But – depression and other mental disorders CAN be
    effectively treated

                                                                           38

Facts
about Treatment
   Some depressed teens show improvement in 4-6 weeks with
    structured psychotherapy alone

   Most others experience significant reduction of depressive
    symptoms with antidepressant medication

   Supplementary interventions – exercise, yoga, breathing
    exercises, changes in diet – improve mood, relieve anxiety
    and reduce stress that contributes to depression

   Medication is usually essential in treating severe depression,
    and other serious mental disorders (bipolar disorder,
    schizophrenia, etc.)
                                                                     39

Facts about
Antidepressant Medication
   Medications work by restoring brain chemistry back to normal

   Most people experience positive changes; a small percentage
    show agitation and abnormal behavior that may include
    increased suicidal thinking and behavior

   Since 2004, FDA warning recommends close monitoring of
    youth taking antidepressants for worsening of symptoms,
    suicidal thoughts or behavior and other changes

   60% of teens with major depression have suicidal thoughts
    prior to getting treatment; 30% have made a suicide attempt

   Risks of medication must be weighed against the risks of not
    effectively treating depression
                                                                   40

Summary Points
about Treatment
   No single approach or medication works for all teens with a
    mental disorder; sometimes different ones needs to be tried

   But, studies show that 80% of depressed people can be
    effectively treated

   Mental disorders can recur, even if effectively treated at one
    point in time

   On-going monitoring by a physician or mental health
    professional is advised

                                                                     41

Identifying
At-Risk Students
   Most adults are not trained to recognize signs of serious
    mental disorders in teens
   Symptoms are often misinterpreted or attributed to
    Normal adolescent mood swings
    Laziness
    Poor attitude
    Immaturity, etc., etc. …
   The film, More Than Sad: Teen Depression, is designed for
    teens but also helps adults understand what depression looks
    like in adolescents and recognize the warning signs that a
    teen may need help

                                                                42

Reducing Suicide
Risk in Schools
So far, we have emphasized two key suicide prevention tasks of
     school personnel:

   1.   Identify students whose behavior suggests presence of a
        mental disorder

   2.   Take necessary steps to insure that such students are referred
        to a mental health professional for evaluation and treatment,
        as needed

                   What else can schools do?

                                                                     43

Recommended
Actions for Schools
Educate Students about Mental Disorders
   Show and discuss film, More Than Sad: Teen Depression with
    students
   Use lesson plan in Facilitator’s Guide
   Include school-based health or mental health professional

Educate Parents about Mental Disorders and Suicide Risk
   Show and discuss both More Than Sad films at parent meeting
   Recommend other resources for parents listed at end of manual

                                                                    44

Recommended Actions…
Support School Safety and Reduce Bullying
   Address sanctions for bullying and related behaviors in disciplinary
    policies
   Initiate programs to change school culture to be inclusive and
    support student diversity

Support Gun Safety Programs
   Partner with law enforcement, public health and community agencies
    and parents to promote proper gun storage and reduce opportunities
    for unsupervised access to firearms by youth

                                                                           45

Concluding Steps
   Review Additional Resources

   Complete “Test Your Knowledge”

   Complete Participant Feedback Form

         THANK YOU FOR TAKING THIS OPPORTUNITY
           TO LEARN MORE ABOUT TEEN SUICIDE
             AND HOW YOU CAN PLAY A ROLE
                   IN ITS PREVENTION
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